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HCR Update: Appeals Process, Value-Based Preventive Benefits, etc.

Feb 03, 2011

Health Care Reform Update

January 21, 2011

We are adjusting our appeals process  

For plan years beginning on or after September 23, 2010, the health care reform law requires health plans to have an effective internal and external appeals process. We made adjustments to our external process to accommodate the new health care reform requirements. We are working to have all appeals process updates in place by July 1, 2011, the interim final rules grace period deadline (or earlier). Please see this appeals fact sheet for the fine points of our external and internal processes. 

No immediate impact from new guidance on value-based preventive benefits 

Under the health care reform law, nongrandfathered plans cannot have member cost sharing for preventive services required by the U.S. Department of Health and Human Services. To implement this provision, we removed member cost sharing for in-network preventive services required by the HHS, regardless of provider type or treatment setting. This action was consistent with the language in the regulations. 

However, a new Q&A  posted on the Department of Labor website appears to allow for different copayments depending on treatment setting. Responding to a question about whether a plan could have no copay for colorectal cancer preventive services performed in an in-network ambulatory surgery center, but have a copay for the same services in an in-network outpatient hospital setting, the DOL responded that it is permissible to "use reasonable medical management techniques to control costs."  

At this time, the new guidance will not change the way we're implementing the preventive care provision for fully insured and self-funded plans.  

This decision comes after reviewing the language in the Q&A, the regulations and the challenges of this type of value-based benefit design versus the potential cost savings. While the Q&A shows cost sharing may be permissible in some situations, we believe the intent of the health care reform law is to provide members with access to all preventive services required by the HHS at no cost share. With a site-of-care value-based benefit design, this access can be guaranteed only if site-of-care options are available. Differentiating between options for all members in all areas may not be in the best interest of our members because it could require preauthorization or other review processes. 

For more details on our implementation of the preventive care provision, visit the Library section of our health care reform website.

Now you have a single, reliable resource for health care reform information.


This content is provided solely for informational purposes: it is not intended as and does not constitute legal advice. The information contained herein should not be relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisers.

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